Dysmenorrhoea

Dysmenorrhoea means painful menstruation and is a symptom complex with cramping lower abdominal pain that may radiate to the back and leg, gastrointestinal symptoms and general malaise. It is an extremely common complaint and causes considerable morbidity in a proportion of women. It can result from identifiable pathology (secondary dysmenorrhoea) or there may be no obvious cause (primary dysmenorrhoea). Primary dysmenorrhoea occurs most frequently in young women and usually starts within a year or two of the menarche. It is most likely caused by increased prostaglandin production within the uterus and associated uterine hyper-contractility. Other uterotonins discussed are vasopressin and endothelin, both of which may play a role. Secondary dysmenorrhoea is commonly associated with pelvic pathology such as endometriosis or uterine fibroids. Primary dysmenorrhoea responds very well to both non-steroidal anti-inflammatory drugs (NSAIDs) and the oral contraceptive pill. The former agents decrease the production of prostaglandins within the uterus and also have analgesic and anti-inflammatory properties. The combined oral contraceptive pill (COC) decreases the total prostaglandin content of the endometrium since it causes endometrial atrophy. If the pain still persists when these agents have been tried, then taking the COC continuously is often effective since it leads to amenorrhoea. Surgical treatment may be required for some women. Hysterectomy is usually effective in treating symptoms associated with menstruation although other options that are less invasive such as endometrial ablation or laparoscopic uterosacral nerve ablation can be effective. Other treatments that are less widely utilised are also discussed. When secondary dysmenorrhoea is present it is usually necessary to treat the pathology rather than the symptoms alone since the medical treatments discussed above are less effective.